MRI gone awry: Woman’s ordeal with estimates prompts billing warning
That smacking sound of hand to head is often heard when medical bills show up in the mailbox.
The headache-inducing statements can be difficult to digest, not only because the total due may seem excessive, but also because the lines and figures can be hard to decode.
The people and systems responsible for generating medical bills suffer a similar frustration. Billing systems are complex. Every hospital, clinic and medical practice operates one.
The complexity is compounded due to the fact that each insurance company negotiates a separate contract with each hospital, clinical and medical practice in its network.
While there may be considerable overlap, payments from health insurance companies to health care providers, known as “reimbursement,” can vary substantially by carrier, by provider and by the region where the procedure is performed.
The level of complexity increases with every health care provider and health insurance carrier these billing systems track.
Mistakes happen. One Grand Junction woman, who tried to get ahead of her medical bills, can attest to that, as well as the confusion that followed.
Diana Budig is new to the city. She moved here from Alaska, where she worked for a radiology practice that routinely performs magnetic resonance imaging exams for patients. An MRI is a non-invasive diagnostic procedure that creates electronic images of living tissue.
On Oct. 8, Budig reported to St. Mary’s Hospital to receive an MRI on her shoulder as ordered by her doctor, Mark G. Luker.
Upon arrival, Budig was handed a worksheet that estimated the cost of the procedure and the amount she was required to pay before the MRI could be administered.
The worksheet listed the price for an MRI on one shoulder as $5,455. It estimated the amount Anthem, her health insurance carrier, required out-of-pocket in advance of the procedure was $659, or 15 percent of the total — an amount known also known as co-pay or co-insurance.
Budig balked. She was shocked by the $5,455 figure. She had already been quoted a price of $2,400 for the same procedure in Anchorage, Alaska.
“I was going, ‘No, I’m not paying this. That is ridiculous. That’s not 15 percent of what this should cost.’ ” Budig said.
She decided to cancel the procedure and asked for her doctor’s order so she could take it to Alaska on a return trip and get the MRI performed there.
While Budig waited, a St. Mary’s radiology technician, concerned by the cancellation, consulted with her about the situation and then asked a third person familiar with worksheet estimates to explain. The person, who Budig could not identify, reportedly said there was a glitch in the St. Mary’s system that estimates charges. She told Budig the worksheet incorrectly listed the price of an MRI for two shoulders instead of one. The true cost was $2,700.
Ultimately, Budig decided to go ahead with the procedure but refused to pay more than $150 in co-insurance. St. Mary’s agreed. The procedure was performed. Nearly 30 days hence, Budig has yet to receive a final bill for the MRI.
Budig’s concern is for people who may have paid the hospital more than required based on an incorrect estimate and don’t know it, she said.
She doubted whether patients owed reimbursement actually receive it.
“If only there was a way to say, ‘Hey, if you’ve had a shoulder MRI at St. Mary’s, we want to talk to you,’ ” she said.
Dan Prinster, St. Mary’s vice president for business development, said he was unaware of any glitches in the ClearQuote software system the hospital uses to create estimate worksheets.
ClearQuote bases estimates on a number of factors, including the type of insurance involved, the deductible and coinsurance amounts, and the patient’s demographics, Prinster said.
St. Mary’s records reflect the estimate for Budig’s MRI was manually changed to $2,700 and the hospital collected only $150 as coinsurance before conducting the procedure, he said.
A team of patient advocates monitors bills and writes checks to reimburse patients who overpay as a result of billing errors, Prinster said.
There are several fail-safe mechanisms built into the St. Mary’s system to prevent overbilling, but the system is complex and mistakes happen, he said.
Any mistakes in an estimate are usually intercepted when a final bill is issued. Budig’s final bill should reflect the correct charge, he said.
If a mistake goes uncorrected after St. Mary’s processes the bill, it is normally caught by the health insurance carrier, which knows the amounts it is under contract to pay the hospital for any given procedure, Prinster said.
A more common problem is determining whether a particular medical service is covered by insurance. Variations in the method used to conduct the procedure may result in one variation being covered under a health insurance plan but the other not being covered, he said.
Like many hospitals, St. Mary’s medical records system must keep track of more than 1,000 health insurance plans, each with a different number and level of health benefits.
For each plan, the hospital is only allowed to charge a certain amount. The amount allowed often differs from plan to plan for the same medical service.
Prinster said the variation between plans and benefits contributes to the high cost of medical care. Complexity adds administrative expense, which increases overall health care costs, he said.
“If there was more standardization it would make these process easier and less prone to potential errors,” he said.
Prinster urged patients concerned about the issue to consult first with their insurance carrier to make sure the service they seek is a covered benefit and to learn in advance how much they may be required to pay as deductible or coinsurance to have the service performed.